Genital Herpes

Doctor Information

Patient Information

You will readily reveal the following:Opening Line:"I didn't really want to come because its embarrassing, I've been building up the courage to come here, and am feeling very nervous."

Only continue with the history if the doctor reassures you and you feel comfortable in their presence.

Presenting complaint:You have some painful spots down below that you noticed 2 days ago.

History of presenting complaint: They really hurt, especially when you wee, and when you tried to look with a mirror, they looked like mouth ulcers. You are really embarrassed to talk about this, but now it hurts so much you are walking funny because your knickers are rubbing on them. You desperately want something for the pain, and preferably to make them go away.

Reveal the following only if asked:You have regular periods which started when you were 12. You have no vaginal discharge or bleeding between periods. You have no abdominal pain or fever, and you are generally well in yourself. You haven't asked your boyfriend if he has any spots because it's embarrassing as you suspect this is acne, and you'd rather he didn't know about it.

Past Medical History:You haven't had any major problems, and have been lucky that you haven't had any acne in the past. You don't take any regular medications and you have no known allergies. You've never had cold sores.

Social History:You do not smoke and you do not drink alcohol. You are a student at business college and live with your parents and two younger brothers. You have good friends.

Sexual History:Reluctantly answer questions about your sexual history: you do have a boyfriend who is in college with you (also 17), and you do have vaginal sex with him. The sex is consensual. You don't have any other form of intercourse. You have been together now for 4 months, before this you have had boyfriends but never had sex. You haven’t started any tablet contraception because your mum is nosy and she would go mad if she found pills in your drawers, but you do use condoms most times (sometimes you don't have any on you). You're not interested in starting any tablet contraception today.

Ideas: You have had an outbreak of acne on your 'down-below' bits

Concerns:You are highly embarrassed and also in a lot of pain, you're also concerned that if this acne could spread to your face.

Expectation: To get some cream for them

Your Reaction:If you are told this is sexually transmitted, you want to know if there is a treatment to get rid of it. You haven’t had sex with anyone apart from your boyfriend so where has this come from? Has he been cheating on you? (if asked he had a long term girlfriend before you started going out). You will accept any medication offered and will agree to go to a sexual health clinic as long as your details remain confidential. You will also agree to tell your boyfriend and ask him to get screened if you find out that he could have contracted this prior to going out with you.

Examination Findings

Examination

You agree to an external examination of the genitalia only (you do not want swabs, nor anything called a speculum inside you), and only if a chaperone is present regardless of the gender of the examining doctor.

The findings are as followsMultiple fluid filled blisters approximately 4-5mm diameter, tender to touch, around the vulva bilaterallyNo inguinal lymphadenitis

Mark scheme

Data Gathering

POSITIVE INDICATORSClarifies the problem & nature of decision requiredGathers information from history taking, examination and investigation in a systematic and efficient manner.Is appropriately selective in the choice of enquiries, examinations & investigationsIdentifies abnormal findings or results & makes appropriate interpretations

Enquires about / offers chaperone

Good sexual history

Asks about taking swabs for other sexually transmitted infections

NEGATIVE INDICATORSMakes immediate assumptions about the problemIntervenes rather than using appropriate expectant managementIs disorganised/unsystematic in gathering informationData gathering does not appear to be guided by the probabilities of disease.Fails to identify abnormal data or correctly interpret themFails to offer chaperone

Advises discussing with partner, and able to explain that partner may not have been unfaithful

NEGATIVE INDICATORS

Fails to consider common conditions in the differential diagnosisDoes not suggest how the problem might develop or resolveFails to make the patient aware of relative risks of different approachesDecisions on whether/what to prescribe are inappropriate or idiosyncratic.Follow-up arrangements are absent or disjointed

Unable to construct a problem list and prioritise

Fails to address important steps in further management: screening for other STI's, addressing contraception.

Inter Personal Skills

POSITIVE INDICATORSExplores patient’s agenda, health beliefs & preferences.Shows responsiveness to the patient's preferences, feelings and expectationsEnhances patient autonomyProvides explanations that are relevant and understandable to the patientResponds to needs & concerns with interest & understandingBacks own judgment appropriatelyDoes not allow own views/values to inappropriately influence dialogue

NEGATIVE INDICATORSDoes not inquire sufficiently about the patient’s perspective / health understanding.Pays insufficient attention to the patient's verbal and nonverbal communication.Fails to explore how the patient's life is affected by the problem.Uses inappropriate (e.g. technical) languageInappropriately influences patient interaction through own views/valuesTreats issues as problems rather than challengesAppears patronising or inappropriately paternalistic

Management

Explanation:Genital herpes is a common infection caused by the herpes simplex virus (HSV). It causes painful blisters on the genitals and the surrounding areas. As genital herpes can be passed to others through intimate sexual contact, it's often referred to as a sexually transmitted infection (STI). Genital herpes is a long-term condition. The virus remains in your body and can become active again. The average rate of recurrence is four to five times in the first two years after being infected. However, over time, it tends to become active less frequently and each outbreak becomes less severe.

Management:There are several areas to cover in this case. Firstly there is the presenting complaint - a fairly typical history of genital herpes, first presentation. This should prompt you to ask a full sexual history - often if there is one sexually transmitted infection, there is likely to be another. Although she does not have symptoms of any other STI, she should still be advised to go to a GUM/sexual health clinic for testing - many people remain asymptomatic.

The next issue is her age. Seventeen year old individuals can legally have sex, but can also be a vulnerable group - it is still important to ascertain the age of her boyfriend, and to ensure she is not being coerced. You can reassure her that what she tells you will remain confidential, as long as she is not in any danger or doing anything illegal.

Finally there is the issue surround infidelity. Genital herpes can be asymptomatic, and can also be recurrent with long periods of latency in between. It is possible that her boyfriend has been unfaithful, but that is not necessarily the case. If he has been sexually active before, he could have contracted it then without realising. If possible she should be persuaded to talk to him and have him tested and treated as well, otherwise infections will simple pass back and forth.

Genital herpes is caused by the herpes simplex virus, either type 1 or 2. It is spread by direct contact with any lesion, including mouth, hands or sexually. Up to 80% of infected people are asymptomatic, and the latent virus can reactivate causing recurrent genital herpes. Along with the painful blisters, symptoms can also include vaginal discharge, dysuria, fever. The examination findings externally are usually bilateral blisters/vesicles that are very tender. The diagnosis should ideally be made at a sexual health clinic, but if the history and examination findings are consistent with genital herpes, treatment can be offered in primary care along with advice to have further investigation.

Diagnosis based on clinical findings alone can be unreliable, therefore virology swabs are usually taken in GUM clinics, and is the most common way in the UK to diagnose the condition.

The management is different for a first episode compared with recurrent episodes. All patients should be advised to have a full sexual health screen at a specialist clinic (see local guidelines), and special attention should be paid to anyone who is immunocompromised (pregnant, HIV) or seems unusually unwell (think herpes meningitis). The treatment is oral aciclovir (200 mg five times a day) within 5 days of the start of the episode or while new lesions are forming. Continue for 5 days, or longer if new lesions are still forming while on treatment, along with simple analgesia (paracetamol/ibuprofen) and barrier cream (something like sudocreme or vaseline) for topical relief. Avoid sex until the lesions are gone. Avoid sharing towels. Although there is no cure for genital herpes, but many people will not get symptoms, and those that do tend to improve over time.

Recurrent episodes can often be managed with self care measures alone (pain relief, either systemic or topical). If not, the same dose and course of oral acyclovir can be used. If episodes are frequent or not responding to treatment, consider specialist referral.

What if the patient won't go to a GUM clinic???? - (the following is taken from NICE CKS)

For people unwilling to attend GUM:

Follow up after 5 days to determine the effectiveness of treatment and discuss the virology swab result (if taken). Explain that even with a negative swab result, they may still have genital herpes. The diagnosis can only be confirmed by further attacks and herpes simplex virus detection.

Explain that a first clinical episode may not necessarily indicate recent infection nor that a partner has been unfaithful (if appropriate). They could have acquired the infection (sub-clinically) years previously, or the herpes virus (type 1) may have spread from elsewhere on their body (such as lips or fingers).

Explain that transmission can occur when there are no symptoms (asymptomatic shedding), but the risk is higher when symptomatic. Advise the person to:

Avoid sex (including orogenital sex) if lesions are present.

Use condoms with new or uninfected partners. Explain that condoms cannot completely prevent transmission, due to close skin contact or contact with infected secretions during foreplay.

Advise people who are concerned about transmitting genital herpes to long-term partners that their partner may already be infected even if they do not have symptoms, and that they should seek advice from a specialist in GUM for screening.

Explain there is no cure for genital herpes at present. However, symptoms improve (reduce in frequency and severity) with time and can be well controlled. On average, people have 4–5 attacks of genital herpes a year in the first 2 years.

Try to convince the patient to have a sexual health screen in house (if offered) - remember that if the patient doesn't want a pelvic exam, a self-taken vaginal swab or first-void urine specimen should be sent for testing for chlamydia, and gonorrhoea can be tested from a urethral swab.